The 2019-20 Budget: Department of State Hospitals

The 2019-20 Budget: Department of State Hospitals GABRIEL PETEK LEGISLATIVE ANALYST FEBRUARY 2019 Summary The Governor’s budget proposes $2 billion for the Department of State Hospitals (DSH) in 2019-20—an increase of $59 million (3 percent) from the revised 2018-19 level. In this report, we assess four specific DSH proposals and offer recommendations for legislative consideration. Direct Care Nursing. The Governor’s budget proposes several changes to the way nurses are staffed at state hospitals, and $15 million (General Fund) and 421.3 positions to implement these changes. We recommend the Legislature approve the proposed standardization of nursing staffing ratios, but require an independent analysis of DSH’s clinical staffing levels. We also recommend approving only a portion of the proposed medication room staffing on a pilot basis to determine the effect on patient outcomes. Court Evaluations, Reports, and Cognitive Rehabilitation Therapy. The budget proposes $8.1 million (General Fund) and 43 positions to address workload related to court evaluations and reports and cognitive rehabilitation therapy. We recommend the Legislature reject the proposed resources for dedicated clinical and administrative staff as they appear unnecessary and instead have DSH develop a plan to pilot a clinical peer-review approach. Workforce Development. The Governor’s budget proposes $1.8 million (General Fund) and eight positions to create a forensic psychiatric residency program and expand DSH’s nursing training partnerships with community colleges. We recommend approving the proposed psychiatric residency program on a pilot basis to assess its effectiveness and requiring DSH to report on why its cost of the partnerships cannot be offset by community college instructional funding. Hospital Police Academy. To reduce hospital police officer vacancies, the Governor’s budget proposes $5.8 million (General Fund) and three positions to expand the DSH Police Academy on an ongoing basis. We recommend only approving three-year funding as the additional police may not be needed after that time. OVERVIEW Department Provides Inpatient and Outpatient with counties to provide in-patient mental health Mental Health Services. The Department of State services in around a dozen additional locations (typically Hospitals (DSH) provides inpatient mental health county jails) throughout the state. In addition, DSH services at five state hospitals (Atascadero, Coalinga, provides outpatient treatment services to patients in the Metropolitan, Napa, and Patton). DSH also contracts community. The 2018-19 budget included resources to analysis full gutter 2019-20 BUDGET provide in-patient mental health service to about of January 14, 2019, the department had about 6,200 individuals in state hospitals and roughly 1,100 patients awaiting placement, including about 500 individuals in contracted programs. The budget 800 IST patients. also included resources to provide out-patient Operational Spending Proposed to Increase services to around 700 individuals. Patients fall by $59 Million in 2019-20. The Governor’s into one of two categories: civil commitments budget proposes total expenditures of $2 billion or forensic commitments. Civil commitments ($1.8 billion from the General Fund) for DSH are generally referred to the state hospitals for operations in 2019-20, which is an increase treatment by counties. Forensic commitments are of $59 million (3 percent) from the revised typically committed by the criminal justice system 2018-19 level. This increase is primarily due to and include individuals classified as Incompetent to $35 million in one-time funding proposed for Stand Trial (IST), Not Guilty by Reason of Insanity, deferred maintenance projects and $25 million Mentally Disordered Offenders (MDOs), or Sexually related to two staffing proposals resulting from Violent Predators. Currently, about 90 percent of DSH’s ongoing Clinical Staffing Study, which we the patient population is forensic in nature. As discuss in greater detail below. DIRECT CARE NURSING Background DSH, the minimum staffing standards do not result in enough nurses to effectively deliver adequate DSH Subject to Minimum Staffing Standards care. For example, the department indicates that for Nurses. Patients admitted to DSH are housed these ratios do not account for changes in the in different units throughout the hospitals based on needs of the patient population since they were various factors including their patient type (such first established in the early 1980s. According as whether they are an MDO or a Sexually Violent to the department, the patient population has Predator) and the level of care they require—also become more difficult and violent since that time, known as their acuity. The department staffs which has increased the need for more intensive these units with employees known as “level of care. For example, patients experiencing a mental care staff” who provide treatment services to the health crisis or feelings of suicidality require patients. Level of care staff include various types of additional staff. To accommodate this workload, nurses (such as registered nurses and psychiatric the department typically staffs more nurses on its technicians) and other clinical staff including units than required by the minimum standards. DSH psychiatrists, psychologists, and social workers. reports that these additional staff have resulted DSH is required to meet certain minimum staffing in it requiring more positions than it is currently standards on its units. For example, DSH must approved for. Accordingly, the department has comply with Title 22 of the California Code of relied on significant amounts of temporary help Regulations, which sets the standards for operating positions that have not been officially established in many of the department’s beds. In particular, it the budget. In addition, the department has made requires a certain minimum number of nursing staff significant use of overtime—including mandatory based on patient acuity and associated treatment overtime—to maintain its current level of staffing. needs for each different eight hour nursing shift For example, a 2016 Little Hoover Commission (meaning morning, afternoon, or overnight), as study found that DSH nurses had worked about shown in Figure 1. Title 22 nursing staff have many 194,000 hours of mandatory overtime in 2014-15. responsibilities, including patient observation, Currently, DSH has no statewide standards medication distribution, and patient escorting. established for the number of additional nurses Actual Nurse Staffing Generally Exceeds that are necessary on its units to provide adequate Minimums and Varies by Hospital. According to care. This has resulted in each hospital using its 2 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2019-20 BUDGET own methods for establishing Figure 1 the number of nurses it views Minimum Nurse to Patient Staffing Requirements as adequate. For example, Under Title 22 DSH-Atascadero uses the Patient Classification Rating System, Patient Acuity which evaluates patients’ stability Intermediate Skilled Nursing in various behavioral areas to Nursing Shift Care Facility Acute Facility establish patients’ clinical needs Morning 1:8 1:6 1:6 and corresponding staffing levels. Afternoon 1:8 1:6 1:6 In contrast, DSH-Napa utilizes Overnight 1:16 1:12 1:12 fixed staffing levels for each unit that have been determined by on the unit. Figure 2 (see next page) provides management, such as the clinical more information on the ten categories of units administrator and nursing administrator. established by the study. This allowed the study to Staffing Not Regularly Readjusted in Budget compare the staffing levels in place across the state Process. While DSH requests additional nursing hospitals at units that were delivering similar types staff when activating new units, it does not typically of treatment to similar types of patients. adjust its staffing when the makeup of its units Medication Room Staffing. Nurses who are changes over time. Accordingly, if the population assigned to medication pass duties are required to changes in a way that requires more nurses— prepare, administer, document, and manage the such as more acute patients being admitted— medication administration process within each unit. the department must redirect the resources for Medication pass occurs four times a day, typically the additional staff it needs from elsewhere in in the morning, noon, afternoon, and evening and its budget and rely more on temporary help and can take up to two hours per pass. Medications overtime. Conversely, if its patient population shifts are stored, managed, and administered from a in a way that requires less staffing, the resulting medication room on each unit or brought patient savings are not normally recognized in the budget. to patient using a medication cart. According to DSH Clinical Staffing Study. In 2013, DSH the department, each hospital staffs its medication began evaluating staffing practices at its five rooms with a dedicated psychiatric technician hospitals in a review known as the Clinical Staffing on both the morning and afternoon shifts. The Study. The department initiated the study in an department reports that while these psychiatric effort to assess whether past practices and staffing technicians are counted toward the nurse to patient methodologies—which often differed between staffing ratios, they are generally preoccupied with each hospital, as described above—are in need of their medication-related duties and are unavailable revision, particularly in light of a patient population to deliver other types of care or to respond to that has grown in terms of size, age, and the incidence of violence on the units. number who have been referred by the criminal On-Call Supervisor Used During the justice system. The study is in the process of Evening and Overnight Shift. The first-line reviewing the hospitals’ nursing services, forensic management and oversight of nurses on units in departments, protective services, and the way each DSH is performed by either a unit supervisor or a hospital plans and delivers treatment. supervising registered nurse, depending on various As part of its review of nursing staffing, the factors, such as the medical acuity of the unit. study collected data on the actual amount of staff These supervisors work five days per week during that was being used on each unit throughout the day shift. To ensure that a supervisory position the state hospitals. The study also classified is available during times when these individuals all of the different units into ten categories and are not present, DSH uses a “program officer of two-dozen subcategories based on the type of the day” to fill the role. This role is assigned to services delivered and/or type of patients treated unit supervisors and other managerial staff on a www.lao.ca.gov 3 analysis full gutter 2019-20 BUDGET Figure 2 Ten Unit Categories Established by Clinical Staffing Study Unit Category Type of Patient Admissions Newly admitted patients. Discharge Preparation Patients nearing discharge. Medical Treatment Patients who are receiving medical care. Incompetent to Stand Trial (IST) Patients who are accused of a crime but must be restored to competency Treatment before their court proceedings can continue. Mentally Disordered Offender (MDO) Patients who have been convicted of a violent offense connected to their Treatment severe mental disorder who are committed after completing their prison term as they have been found to pose a danger to the public if released. California Department of Corrections Patients referred for treatment from state prisons. and Rehabilitation Treatment Sexually Violent Predator Treatment Patients who have been convicted of a sex offense and are committed following their release from prison as they have been found to have a mental disorder that makes them likely to engage in sexually violent criminal behavior. Lanterman-Petris Short (LPS) Patients who have been civilly committed by counties. Treatment Multi-Commitment Treatment Various types of patients that are treated together, including MDO, LPS, and individuals found Not Guilty by Reason of Insanity. Specialized Services Treatment Various patients with special needs such as those who are highly aggressive, require sex offender treatment, or are deaf. rotating basis. Individuals who are assigned to the changes. (Under the proposal, the level would program officer of the day role are not present at grow each year until reaching $46 million and the hospital. Instead, they are on call and can be 683.5 position by 2021-22 and annually thereafter.) contacted by staff to address issues that arise on We describe each of these proposals in greater the unit. According to the department, this can detail below. occur several times throughout the night. Standardize Nursing Staffing Ratios. Under the Governor’s proposal, nursing staffing ratios Governor’s Proposal would be standardized for each of the two dozen The administration proposes several changes subcategories of units established by the Clinical related to the way nurses are staffed at the state Staffing Study. Figure 3 gives an example of hospitals. Specifically, the administration proposes the standardized staffing ratios that would be to (1) standardize nursing staffing ratios across the used to staff units for MDOs as well as the three unit categories established by the Clinical Staffing subcategories of units that fall under the category Study, (2) permanently create temporary help of IST Units. As shown in the figure, the staffing positions and a budget for overtime, (3) shift certain ratios can vary depending on the type of patient duties currently carried out by nursing staff to being treated and the unit they are housed in. For administrative staff, (4) create psychiatric technician example, the ratios would require more nurses positions dedicated to staffing medication rooms, on the afternoon shift for IST treatment units that and (5) create registered nurse supervisor positions house patients from admission to discharge than that would provide oversight during the evening for those units that house IST patients in single and overnight shift. In total, the Governor’s budget rooms. In addition, MDO treatment units would includes $15 million from the General Fund and have more nurses than IST treatment units on the 421.3 positions in 2019-20 to implement the above morning and afternoon shift. 4 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2019-20 BUDGET According to the department, the proposed example, the department reports that it often staffing ratios would, on average, reflect staffing delays equipment purchases to generate savings to packages that are already in place across the five offset such costs. To provide greater transparency, state hospitals. This means that the department the administration proposes to permanently shift would not require any additional resources in order the resources that are being redirected to create to staff its units consistent with these standards. 254 temporary help positions and explicitly budget However, because each hospital has its own for about 462,000 hours of overtime. Because the staffing methodology, the department is proposing resources are being shifted, the administration to shift position authority between the hospitals so is not requesting any additional funding for the that the staffing packages in place would be more positions or overtime. uniform statewide. Specifically, DSH-Metropolitan Shift Administrative Duties Away From would receive 142.5 additional positions and Nursing Staff. As part of its review of nursing DSH-Napa would receive 93 additional positions. staffing, the department found that many These positions would be redirected from the other administrative duties that do not require a nursing three state hospitals. background—such as data collection—were We also note that these standards would be being performed by nurses. This requires nurses used to adjust the department’s budget going to be away from their units when performing forward on a regular basis. Accordingly, to the these functions, which could result in the need extent that the makeup of the department’s for overtime or temporary help to fill their roles population changes in ways that require a different while they are away. To address this situation, mix of units, it would adjust staffing accordingly. the department is requesting 50 administrative This would mean that an overall increase in the positions (largely staff service analysts) to perform treatment need of patients would result in the these roles. Because this would prevent nurses department requesting additional resources, and, from leaving the unit, the proposal would create to the extent needs declined, its budget would be savings from reduced overtime and/or temporary adjusted to recognize the associated savings. help usage. Accordingly, the administration Create Permanent Temporary Help Positions proposes to use these savings to support the and Overtime Budget. As mentioned previously, proposed positions and no additional funding is DSH makes extensive use of temporary help being requested. positions and overtime to staff their units at their Staff Medication Rooms. The administration current levels. However, the department did not proposes to staff a total of 128 medication rooms formally create the temporary help positions it with dedicated psychiatric technician positions for currently uses and was not explicitly budgeted a 12-hour time period each day that would span for the overtime it uses. Instead, the resources parts of the morning and afternoon shifts. This for the positions and overtime are derived from would prevent the need for nursing staff to be other places in the department’s budget. For pulled from the unit to staff the medication rooms. Figure 3 Examples of Proposed Staffing Standards Shift Unit Category Unit Subcategory Morning Afternoon Overnight IST Treatment Admission to Discharge 1:5.5 1:5.5 1:9.5 Permanent Single Housing 1:5.5 1:6.5 1:9.5 Permanent Dorm/Mixed Housing 1:6.5 1:6.5 1:12 MDO Treatment Permanent Single/Mixed Housing 1:5 1:5 1:10 IST = Incompetent to Stand Trial and MDO = Mentally Disordered Offender. www.lao.ca.gov 5 analysis full gutter 2019-20 BUDGET The department indicates that this would allow duties to non-nursing staff represent an important more nursing staff to be available to treat patients step forward. This is because the proposal would and/or intervene when patients get violent. As result in the nursing portion of the DSH budget a result, the department expects the additional being adjusted for changes in the makeup of its staffing to result in improved patient outcomes patient population and moving some nonclinical (such as shorter lengths of stay) and reduced levels duties away from clinical staff. It would also result of violence. (We note that dedicated medication in greater transparency and legislative oversight as room positions are not being proposed for certain the basis for the department’s staffing packages units such as those that already have relatively high would be clear and consistent across all five state nurse to patient staffing ratios.) hospitals. We note that these proposals generally In order to staff these rooms, the department reflect several recommendations that we made indicates that it would need a total of in our report The 2015-16 Budget: Improved 335 psychiatric technicians, after accounting for Budgeting for the Department of State Hospitals. the time the psychiatric technicians would be . . . But Are Based on Current Practices That away due to various factors such as sick leave Have Not Been Independently Evaluated. The and vacation time. However, in recognition of the proposed staffing ratios and levels of temporary difficulty of hiring this many additional staff at help and overtime are based on current staffing once, the administration proposes to phase in the practices. To date, DSH has not had its current resources over a three-year period. Accordingly, the staffing practices independently reviewed to Governor’s budget proposes $10.7 million (General determine if adjustments could be made that Fund) and 95 positions in 2019-20, growing each would improve outcomes and/or reduce costs. year until reaching $37.4 million and 335 positions For example, it is unclear whether there are in 2021-22 and annually thereafter. additional administrative tasks or other duties that Create Afternoon/Overnight Supervisor could be shifted away from nurses. In addition, Positions. In order to provide better supervision it is possible that different staffing packages that when unit supervisors and supervising registered included less staff than the department uses nurses are away during the afternoon and overnight currently could generate similar outcomes at a shift, the administration proposes to create additional lower cost. Alternatively, additional staff beyond registered nurse supervisor positions. These the proposed level could result in shorter lengths positions would be staffed on state hospital grounds of stay for patients, which could eventually reduce for a 12-hour time period each day that would costs. While the department indicates it will span parts of the evening and overnight shift. While continue reviewing its staffing standards going there is one supervisor per unit during the day shift, forward—particularly with regard to identifying other the administration indicates that the lower level of administrative duties that could be shifted away patient activity and administrative duties during the from clinicians—such a process would lack the afternoon and overnight shift mean fewer registered independence that could be necessary to identify nurse supervisors would be necessary. In view of the significant efficiencies. proposed changes, the Governor’s budget proposes Unclear Whether Additional Medication Room a total of $4.3 million from the General Fund and Staff Necessary. The department’s primary goals 22.3 positions in 2019-20, growing to $8.6 million in proposing additional medication room staffing and 44.5 positions annually beginning in 2020-21. are to free-up the staff currently fulfilling these roles so that they can provide additional care and be LAO Assessment available to help reduce violence. It is reasonable Nursing Adjustments Represents Important to think that additional staffing could result in Step Forward . . . The administration’s proposal such outcomes. However, the department has to create uniform staffing standards for the state not been able to provide data demonstrating that hospitals, appropriately budget for temporary help a lack of staff has negatively impacted outcomes and overtime usage, and reassign administrative or contributed to problems with violence. For 6 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2019-20 BUDGET example, the department does not collect data established in the Clinical Staffing Study; on patient violence in a way that would allow it to (3) an assessment of whether staff are assigned show that violence rates increase when nurses appropriate responsibilities, or whether more tasks must leave their units to staff medication rooms. As could be assigned to nonclinical staff or less costly such, it is unclear on the extent to which additional clinical staff; and (4) recommendations to ensure medication room staff are necessary. the department is utilizing its staff as efficiently and Afternoon/Evening Supervisors Seem effectively as possible. We estimate that such an Reasonable. Given the difficulty inherent in analysis would likely cost in the low hundreds of providing adequate supervision while not physically thousands of dollars. present, we find that the proposal to provide Pilot Medication Room Staffing. It is DSH additional registered nurse supervisors possible that the proposed additional nursing merits consideration. We note that the California staff for medication rooms would free up other Department of Corrections and Rehabilitation nurses on units to help better deliver care and (CDCR)—which operates mental health facilities reduce violence. However, given the lack of data similar to those operated by DSH—staffs its units demonstrating that this is likely to occur and with nursing supervisors on all shifts. the magnitude of the proposed resources, we recommend that the Legislature approve only a LAO Recommendations portion of the positions on a pilot basis. Specifically, Approve Nursing Adjustments, but Require we recommend that the Legislature approve Evaluation. We recommend that the Legislature $7.1 million (General Fund) and 63 psychiatric approve the proposed (1) standardization of technician positions in 2019-20 on a three-year nursing staffing ratios, (2) 254 temporary help limited-term basis. This would provide the positions and dedicated budget for overtime, department with sufficient staff to place dedicated and (3) 50 administrative staff to reduce the nurses in 24 medication rooms. This should provide administrative workload currently carried out by the department with enough staff to test the new nurses. These proposals would collectively help staffing package on a wide range of unit types. We ensure that the department’s budget better reflects also recommend that the Legislature require the changes in the makeup of its patient population, department to report by January 10, 2022 on the increase transparency, and make better use of effect that the additional staffing has on patient nursing staff. length of stay and violence rates. We note that this analysis could be carried out by the independent However, the proposed staffing standards are consultant conducting the comprehensive clinical reflective of current practice that has not been staffing analysis that we recommend above. subject to independent evaluation. Accordingly, we recommend that the Legislature require DSH Approve Evening/Overnight Supervisors. to contract with an independent consultant for We recommend that the Legislature approve the a comprehensive clinical staffing analysis. Such proposed registered nurse supervisor positions as an analysis should include: (1) an evaluation these positions would ensure that supervisory staff of the department’s clinical staffing—including are physically present to address issues that arise both nursing and other clinical staffing; (2) an on the units. It would also bring DSH staffing more assessment of the appropriate number and type in line with the staffing used by CDCR on similar of clinical staff necessary to provide treatment mental health units. for patients assigned to each category of unit www.lao.ca.gov 7 analysis full gutter 2019-20 BUDGET COURT EVALUATIONS, REPORTS, AND COGNITIVE REHABILITATION THERAPY Background the patient also completes the required evaluations and reports, and provides court testimony. We note DSH Clinicians Required to Provide that DSH-Napa uses a hybrid approach. Specifically, Evaluations, Reports, and Testimony. Given that the hospital generally requires the treating clinician around 90 percent of the patient population is complete this workload but maintains a team committed to DSH from the criminal justice system, dedicated to this workload for IST patients. the department’s clinicians are frequently required The department reports that there are several to provide courts with evaluations, reports, and problems associated with having the clinician who testimony regarding patients, including IST, MDO, treats the patient also complete evaluations and Not Guilty by Reason of Insanity, and Sexually reports and provide testimony regarding that patient. Violent Predator patients. Figure 4 provides an Specifically, DSH is concerned that this practice: example of the various reports courts require related to individuals found IST due to their mental • Creates a Conflict of Interest. The condition. The department estimates that it is department indicates that having the treating required to complete roughly 11,000 mandated clinicians carry out this workload for their court reports each year. patients can represent a conflict of interest. After completing evaluations and/or reports, For example, it might require the clinician clinicians are often required to attend court to indicate to a court that he or she has hearings and provide testimony regarding their been unable to effectively treat a patient. In patient reports and evaluations. When this addition, the department reports that there happens, clinicians are frequently required to have been incidents in which patients have travel to the court that committed the patient to attacked their clinicians due to the testimony participate in hearings. provided about them. According to DSH, such Currently, each state hospital has its own factors undermine the ability of clinicians to approach to handling the above workload. For complete this workload objectively. example, DSH-Atascadero and DSH-Coalinga • Relies on Clinicians That Lack Necessary have specific clinical staff dedicated to completing Expertise. DSH indicates that, to be this workload. In contrast, DSH-Metropolitan and effective in completing the required court DSH-Patton do not have such dedicated staff. At evaluations and reports, clinicians must be these particular hospitals, the clinician who treats familiar with the judicial system as well as Figure 4 Examples of Reports Required for Incompetent to Stand Trial Patients Report Content Progress Reports Information on progress towards competency and whether antipsychotic medication remains necessary. Reports required 90 days after commitment and every six months after that until the patient is restored to competency. Certificate of Restoration Notifies court that patient has been restored to competency. Unlikely to Gain Competency Notifies court that there is no substantial likelihood that the patient will be restored to competency. Maximum Term of Commitment Notifies court that the patient is within 90 days of the maximum term of commitment without being restored. 8 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2019-20 BUDGET the legal requirements related to the required violence. Moreover, a 2011 study at DSH-Patton documents. However, DSH reports that many showed that providing cognitive rehabilitation clinicians currently lack the legal training therapy to patients with cognitive deficits reduced to carry out these tasks effectively. The their violence by 38 percent. Second, identifying department also indicates that courts have and treating patients with cognitive deficits could complained about the quality of the work improve treatment outcomes. For example, in a carried out by some clinicians. study also carried out at DSH-Patton, the presence • Reduces Quality of Care. This workload of cognitive deficits was associated with longer takes away time clinicians could otherwise lengths of stay. According to the department, this spend treating their patients. As such, the suggests that treating such deficits could result in department is concerned that the required shorter lengths of stay. Moreover, the department workload could reduce the quality of care that reports that providing information about patients’ patients receive. clinical deficits to clinicians can help them better structure the treatment they provide, even if the Forensic Case Management and Data patient does not receive cognitive rehabilitation Tracking (FCMDT) Staff. While clinicians complete therapy. Despite these benefits, the department the reports, evaluations, and provide testimony, the reports that three of the five state hospitals do department employs FCMDT administrative staff not offer cognitive rehabilitation therapy. While to assist them with this workload. These FCMDT DSH-Patton and DSH-Atascadero offer such staff are responsible for the overall coordination therapy, the department reports that these hospitals and tracking of the required reports and the are currently only able to provide such treatment to coordination and completion of all paperwork and less than 1 percent of the patients needing it. responses to court questions. FCMDT staff are also responsible for data tracking and analytical Governor’s Proposal efforts related to various aspects of state hospital The Governor’s budget proposes a total General operations, such as admissions and discharge Fund augmentation of $8.1 million and 43 positions data, as well as bed capacity. The department in 2019-20 to help address workload related to does not currently have a standardized approach to court evaluations and reports, as well as cognitive staffing these positions at each state hospital, but rehabilitation therapy. (Under the proposal, the it reports that each FCMDT staff member typically level of resources would generally increase each has a caseload of 200 to 300 patients, though at year until reaching $18.1 million and 94.6 position some hospitals the caseload can be higher. On in 2022-23 and annually thereafter.) The specific average, each hospital currently has roughly seven components of the Governor’s proposal include: positions dedicated to this work. Neuropsychological Evaluations and • Additional Staff for Court Evaluations, Treatment. Neuropsychological evaluations are Reports, and Testimony Workload used to determine patients’ current abilities to pay ($4.1 Million). The administration proposes attention, remember information, plan and organize, additional clinical staff that would be and use language. This allows clinicians to dedicated to the workload associated with determine whether patients have cognitive deficits court evaluations, reports, and testimony, and could benefit from cognitive rehabilitation primarily to eliminate the conflict of interest therapy, which is designed to improve patients’ that exists when treating clinicians perform cognitive function. these tasks related to their patients. Based on a review of the amount of workload generated The department reports that it is important to by each patient type, the department identify and treat cognitive deficits for two primary proposes staffing standards that would reasons. First, identifying and treating patients with establish the number of clinicians it needs. cognitive deficits can reduce violence. For example, Based on these standards, the administration research conducted at DSH in recent years has is proposing a total of 53.1 new positions found that cognitive deficits were predictive of www.lao.ca.gov 9 analysis full gutter 2019-20 BUDGET (largely senior psychologist specialist senior psychologist specialists). Under the positions) that would be phased in over proposal, these staffing levels would be three years, with 18.5 positions proposed for adjusted regularly to account for changes in 2019-20. Under the administration’s proposal, the number of patients admitted. staffing levels would be regularly adjusted • Cognitive Remediation Therapy Pilot based on the proposed staffing standards ($954,000). The administration proposes to account for changes in the makeup of the to begin treating patients with cognitive population. DSH plans to refine the staffing remediation therapy on a pilot basis at standards in future years as it collects more DSH-Metropolitan and DSH-Napa. According data about the amount of resources this to the department, patients that receive this workload requires. therapy would be less likely to engage in • Additional FCMDT Staff ($986,000). In order violence and may have better outcomes. To to standardize staffing for FCMDT workload, implement the pilot, the Governor’s budget the administration proposes a departmentwide proposes seven positions (including senior standard of 250 patients per staff member psychologist specialists and psychiatric and to use associate government program technicians) in 2019-20. analysts and staff service analysts (rather than the varying classifications currently LAO Assessment being used) for the workload. In addition, Proposed Evaluations, Reports, and the administration is proposing to hire five Testimony Staffing Potentially Unnecessary. One additional associate government program of the primary justifications of the department’s analysts to expand its data collections efforts proposal to hire staff dedicated to evaluations, to further refine the staffing standards for the reports, and testimony workload is to remove evaluations, reports, and testimony workload the conflict of interest that exists when treating described above on an ongoing basis. In view clinicians carry out these duties with respect to of the above changes, the Governor’s budget their patients. We find that this is a legitimate proposes 7.3 positions in 2019-20. Under concern. However, an alternative way to remove the proposal, each hospital would have an this conflict of interest—potentially without the need average of roughly ten positions dedicated to for additional staffing—is to create a peer-review the work. We note that these staffing levels system in which clinicians do not carry out these would be adjusted regularly to account for duties for their own patients, but rather do so for changes in the size of the patient population. the patients of other clinicians. • Increased Use of Neuropsychological The department also put forth this proposal due Evaluations ($2 Million). The Governor’s to concerns about the quality of the work done by budget proposes additional resources to use clinicians without specialized training in it. We note, neuropsychological evaluations on a larger however, that the department was unable to provide scale to identify more patients with cognitive data regarding the magnitude of the problems with deficits. According to the department, this the quality of clinicians’ work. We also note that it would enable clinicians to identify patients is possible that these problems could be addressed who are at risk of violence and to better by providing additional training to existing DSH tailor existing treatments to meet the needs clinicians. This training could also help clinicians of patients with cognitive deficits. Based perform their other work more effectively. For on research conducted at DSH-Patton, example, if clinicians received in-depth training on the department estimates that roughly what the legal standard is for restoring IST patients 25 percent of patients admitted would need to competency, it would likely help them provide an in-depth neuropsychological evaluation competency restoration more effectively. after receiving an initial screening from their unit psychologist. Accordingly, the Governor’s Finally, the department intends to reduce budget proposes 10.2 positions (largely treating clinicians’ workload by shifting these 10 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2019-20 BUDGET duties to dedicated staff so that the clinicians determine whether it should continue, be modified, have more time to treat their patients. However, or eliminated in the future. the department did not provide any information LAO Recommendations to show that there is a problem with the level of care patients currently receive. For example, the Reject Staffing for Evaluations, Reports, and department did not provide data showing that Testimony and Direct DSH to Develop Plan patient outcomes are better at hospitals, such as for a Peer-Review Pilot. In view of the above DSH-Patton, where clinicians are not required to concerns, we recommend that the Legislature perform this workload. reject the proposed funding for dedicated staff for Inadequate Justification for Additional FCMDT court evaluations, reports, and testimony workload, Staff. The department indicates that it needs including the related staffing standards proposed by additional FCMDT staff to bring all state hospitals the administration. Instead, we believe that it would to the proposed standard of 250 patients per staff be more effective for the department to implement member. However, the department did not provide a peer-review approach on a pilot basis beginning data demonstrating that there are problems with in the budget year in which treating clinicians the work carried out by FCMDT staff at the state complete this workload for each other’s patients. hospitals who staff below this standard. As such, it As such, we recommend that the Legislature direct is unclear why additional staff are necessary. the department to provide a plan for implementing In addition, the primary justification for the five such a pilot by April 1, 2019, including information additional associate government program analyst on what resources, if any, it would need and how it positions was to collect data to help refine on an would go about selecting participating clinicians. ongoing basis the staffing standards proposed for Reject Additional FCMDT Staff. Given that the the evaluation, reports, and testimony workload. department did not demonstrate that its existing However, these positions would only be necessary FCMDT staff are unable to effectively complete their if the Legislature approves the proposal to establish workload, we recommend the Legislature reject the staffing standards for evaluation, reports, and proposed augmentation for these staff. We do not testimony workload. have concerns with the department standardizing Neuropsychological Evaluations Appear the classifications used to complete this workload Necessary. We find merit in the proposal to expand or establishing staffing standards for it, so long the testing of patients with neuropsychological as it can be done within existing resources. evaluations to identify those with cognitive deficits. Finally, because the primary justification for the This should allow the department to identify five associate governmental program analysts is patients at risk of violence in order to better prevent collecting data to refine the standards for staffing it. It would also allow treatment for such patients to evaluation, reports, and testimony workload, be better tailored to their needs. which we do not recommend approving, we also recommend rejecting those proposed positions. Cognitive Remediation Pilot Merits Consideration, but Proposed on Ongoing Approve Funding for Neuropsychological Basis. While the department is proposing to Evaluations. In light of the potential benefits, we pilot cognitive remediation therapy at two state recommend approving the funding that would allow hospitals, it is proposing resources for the program the department to expand testing of patients with on an ongoing basis. This means that the program neuropsychological evaluations. As mentioned would continue to be funded even if the results above, this could help the department better of the pilot demonstrate that it is not effective. In prevent patient violence and improve treatment for addition, while the department plans to evaluate patients with cognitive deficits. the program, there is no specific requirement that Approve Funding for Cognitive Remediation a report on the outcomes of the pilot be provided Pilot on Limited-Term Basis, Require Evaluation. to the Legislature. This would make it difficult for We recommend that the Legislature approve the Legislature to evaluate the pilot program and three-year limited-term funding for the proposed www.lao.ca.gov 11 analysis full gutter 2019-20 BUDGET cognitive remediation pilot at two state hospitals, the pilot by January 10, 2022, as this would allow rather than ongoing funding as proposed by the the Legislature to determine whether to approve Governor. We also recommend that the Legislature ongoing and/or expanded funding for cognitive direct the department to report on the outcome of remediation therapy as part of the 2022-23 budget. WORKFORCE DEVELOPMENT BACKGROUND Recruitment and Retention of Nursing Staff Recruitment and Retention of DSH Employs Psychiatric Technicians and Psychiatrists Registered Nurses. State law and regulations require DSH to maintain a specific ratio of nurses DSH Employs Psychiatrists. Psychiatrists—who to patients on its units in the state hospitals. (For are medical doctors that specialize in the diagnosis more information on these ratios, please see the and treatment of mental health conditions—deliver “Direct Care Nursing” section of this report.) For a significant portion of the care provided to DSH example, the department is required to staff a patients. This is because DSH patients often minimum of one nurse for every eight patients require complex pharmaceutical treatments that in its intermediate care units, which are used to psychiatrists are uniquely qualified to prescribe. house patients with less acute treatment needs. Because psychiatrists are medical doctors, an DSH employs a variety of nursing positions to staff individual seeking to become a psychiatrist in these units, including psychiatric technicians and California must complete medical school and a registered nurses. Individuals seeking to become four-year residency program in psychiatry, in which a psychiatric technician or registered nurse in they do clinical rotations under the supervision of California must complete specific coursework other psychiatrists. and/or training requirements to become licensed. DSH Has High Psychiatrist Vacancy For example, individuals seeking to become a Rates. DSH has had long standing difficulties registered nurse often complete an Associate recruiting and retaining psychiatrists. Currently, or Bachelor’s degree in nursing. (We note that the department reports that about 41 percent individuals with prior experience, such as those of its 259.3 authorized psychiatrist positions who are licensed vocational nurses, do not have are currently vacant. While this is likely partially to complete a degree program.) Those seeking to due to factors unique to DSH (such as DSH pay become a psychiatric technician often complete a often being less than other employers’ and the Psychiatric Technology program. criminal nature of many patients in DSH), there is a DSH Has High Overall Nursing Vacancies. nationwide shortage of psychiatrists. The National DSH also has difficulties recruiting and retaining Institute of Mental Health attributes the national registered nurses and psychiatric technicians at psychiatric shortage to several factors, including some of its hospitals. For example, the department an aging workforce and a lack of residency slots reports that the vacancy rate for its 1,609.5 for individuals seeking to become psychiatrists. authorized registered nurse positions ranged For example, DSH reports that there are only from 13 percent to 18 percent over the past year. 16 individuals per year nationally who complete Similarly, the department reports that the vacancy a residency in forensic psychiatry—the branch of rate for its 3,120 authorized psychiatric technician psychiatry specializing in mental health treatment in positions ranged from 10 percent to 21 percent secure hospitals like those operated by DSH. over the past year. (We note that the vacancy 12 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2019-20 BUDGET rate typically expected for most classifications is establish a new forensic psychiatry residency 5 percent.) As with psychiatrists, this is likely both program. Under this new program, residents due to the similar factors that are unique to DSH would spend a portion of their first two years and (such as the criminal nature of the patients), as well their fourth year at DSH-Napa completing clinical as to a national shortage of nurses. For example, rotations in which they would have their own patient according to an analysis released by the U.S. caseload. (Residents would complete clinical Department of Health and Human Services in 2017, rotations elsewhere in the third year.) The program California may have a deficit of 44,500 registered would admit 4 residents annually, which would nurses by 2030—meaning that the number of result in a total of 16 residents participating once nurses statewide (including in the private sector) it is fully operational. To implement the program, would need to increase by 13 percent—if the the Governor’s budget provides $786,000 and two current level of health care is maintained. DSH positions in 2019-20, increasing to $1.6 million reports having difficulty in filling nursing vacancies annually by 2022-23. Resources in the first year primarily at DSH-Atascadero, DSH-Coalinga, and would be used to hire a senior psychiatrist and DSH-Napa as these state hospitals are not located a program assistant, who would implement and near a major metropolitan area. eventually oversee the program. Once the program Nursing Training Partnerships. In order accepts its first residents in 2020-21, the resources to foster recruitment in nursing classifications, would also be used to pay the residents. DSH has partnered with several community Expansion of Nursing Training Partnerships. colleges and other educational institutions near DSH is requesting $969,000 and six positions its state hospitals over the years. For example, in 2019-20 to expand its registered nurse and DSH-Atascadero has a partnership with Cuesta psychiatric technician training partnerships with Community College in San Luis Obispo to community colleges near DSH-Atascadero, train psychiatric technicians. The department DSH-Coalinga, and DSH-Napa. (The department reports that around 75 percent of graduates reports that the other two state hospitals— from the program have accepted positions at DSH-Patton and DSH-Metropolitan—do not have DSH-Atascadero. In addition, DSH-Coalinga has significant difficulties filling nursing positions given a partnership with West Hills Community College their proximity to major metropolitan areas.) Under in Coalinga and Porterville Community College to the Governor’s proposal, DSH would hire a total of train psychiatric technicians and registered nurses. five additional nurse instructors who would teach The department reports that around 50 percent of courses at Cuesta Community College, West Hills the graduates from these programs have accepted Community College, Porterville Community College, positions at DSH-Coalinga. and Napa Valley Community College. This would enable these colleges to graduate more registered GOVERNOR’S PROPOSAL nurses and psychiatric technician students. Based on information provided by the department, we The Governor’s budget proposes $1.8 million estimate that the proposed expansion could result from the General Fund and eight new positions in well over 100 additional graduates annually. The in 2019-20 to (1) create a forensic psychiatric nurse instructors would also assist in outreach to residency program, and (2) expand DSH’s nursing individuals interested in nursing positions with DSH, training partnerships with several community help them through the hiring process, and serve as colleges. (Under the proposal, the requested mentors once they start working at a state hospital. funding would generally increase each year until The remaining requested position—an associate reaching $2.6 million in 2023-24 and annually government program analyst based in DSH’s thereafter.) headquarters in Sacramento—would support an New Psychiatric Residency Program. DSH expansion of the department’s registered nurse and proposes to partner with Touro University in Vallejo psychiatric technician recruitment efforts. and two county mental health departments to www.lao.ca.gov 13 analysis full gutter 2019-20 BUDGET LAO ASSESSMENT associated with these students. However, the administration’s current proposal would not offset Permanent Funding Proposed for Promising, the cost of the nursing instructors to account but Unproven Residency Program. Given the for this. While the department informs us that high vacancies among psychiatrists and the it will submit a spring Finance Letter to offset need for additional forensic psychiatric residency $370,000 of the $507,000 cost for the three nurse programs, the administration’s proposal to create instructors proposed for DSH-Atascadero, it is not a forensic psychiatric residency program involving currently planning to do so for the nurse instructors DSH-Napa merits legislative consideration. proposed for DSH-Coalinga or DSH-Napa. However, this approach is relatively expensive given that it would cost $1.6 million to produce LAO RECOMMENDATIONS four potential psychiatrists per year once it is fully operational. In addition, it is unclear how effective Approve Forensic Psychiatric Residency the program would actually be at filling psychiatrist Program on Limited-Term Basis, Require positions at DSH as residents in the program could Evaluation. In view of the above, we recommend accept positions outside of DSH. Despite these that the Legislature approve the resources uncertainties about the cost-effectiveness of the requested to establish a forensic psychiatric proposal, the administration is proposing to fund residency program. However, given that the the program on an ongoing basis. We note that program is relatively costly and it is unclear whether this is inconsistent with a separate proposal the it will effectively reduce psychiatric vacancies, we administration has to establish a nurse practitioner recommend that the funding only be approved residency program within CDCR. In that case, the on a six-year limited-term basis. This would allow administration is proposing limited-term funding to one cohort of students to complete the program allow the residency program to be evaluated before and determine whether they ultimately accept funding it on an ongoing basis. positions at DSH. We also recommend that the Expansion of Nursing Training Partnerships Legislature pass budget trailer legislation requiring Appears Reasonable . . . The administration’s the department to report by January 10, 2025 on proposal to expand existing nursing training the extent to which the program has reduced partnerships appears reasonable. This is because psychiatric vacancies. This would allow the the current programs have a proven ability to help Legislature to review the outcomes of the program recruit additional nurses. Moreover, according to when considering whether to approve funding on the department, demand for the programs currently an ongoing basis for the program as part of its exceeds capacity at each of the participating deliberations on the 2025-26 budget. colleges. For example, the department reports Direct Department to Report on Funding for that there are typically 150 applicants for the 30 Expansion of Nursing Training Partnerships. slots in Cuesta Community College’s program for While we have no concerns with the proposal to psychiatric technicians. expand the existing nursing training partnerships . . . But It Is Unclear Why Community College at three state hospitals, we recommend that the Instructional Funding Cannot Offset Costs. Legislature withhold action on the proposal and Given that the nursing instructors DSH would direct the department to report at spring budget provide to the community colleges would allow hearings on why it cannot offset the costs of all five them to enroll additional students, the community proposed nurse instructors with community college colleges should be receiving instructional funding instructional funding. 14 LEGISLATIVE ANALYST’S OFFICE analysis full gutter 2019-20 BUDGET HOSPITAL POLICE ACADEMY Background DSH estimates that this is enough to result in 138 additional hospital police officers each year. Office of Protective Services (OPS). OPS The funds were also used to move the academy is a law enforcement agency within DSH that from DSH-Atascadero to a location in San Luis provides security, enforces laws, and provides Obispo that is shared with the California Military investigatory services at the five state hospitals. Department, in order to provide more space for the Currently, OPS is approved for 657 hospital police larger number of cadets. officer positions to carry out these responsibilities. The 2018-19 budget includes $9.6 million for the Governor’s Proposal operation of OPS. The Governor’s budget proposes $5.8 million DSH Police Academy. After being hired by (General Fund) and three permanent positions for DSH, hospital police cadets are required to attend DSH to operate the DSH Police Academy at its a 14-week DSH Police Academy. At the academy, current, expanded capacity on an ongoing basis— cadets must complete 548 hours of training in meaning three sessions annually. According to multiple disciplines. Some of the courses offered the department, the academy needs to continue include leadership, professionalism, and ethics; operating at its expanded capacity due to the laws of arrest; search and seizure; and cultural following reasons: diversity/discrimination. Prior to 2017-18, the DSH Police Academy was located at DSH-Atascadero • Increased Officer Attrition Rates. According and ran two sessions annually with each session to the department, the current attrition rate is graduating 32 cadets each, in order to address the 5.1 officers per month, an increase over the typical officer attrition rate. (As we discuss below, 2017-18 monthly attrition rate of 4.2, and the the academy was later moved to accommodate 2016-17 rate of 2.7. DSH projects that the a larger number of cadets.) After graduating from rate will continue to increase to 7.1 officer per the academy, individuals are assigned to one of month by 2019-20 and by an additional officer the state hospitals. We note that the department per month in each subsequent year due to has historically had some difficulty recruiting and a projected increase in the number of officer retaining hospital police officers. For example, its retirements. officer vacancy rate has exceeded 20 percent in • High Officer Vacancy Rates. The department prior years. This is likely due to a variety of factors, reports that the 2018 vacancy rate for officers such as the higher salary similar agencies (such as was 15 percent—about three times the rate CDCR) pay officers. typically assumed for most classifications. Academy Temporarily Expanded in 2017-18. DSH expects to have a total of 132.1 Due to the planned activation of 236 beds at vacancies by the beginning of 2019-20. DSH-Metropolitan that required the hiring of over 70 additional hospital police officers and the desire LAO Assessment to reduce the officer vacancy rate, the Legislature Continuing Expanded Academy Appears provided additional General Fund resources over a Necessary, but May Produce Excess Officers two-year period beginning in 2017-18 for DSH to in Future. Absent the additional funding proposed temporarily expand its academy. Specifically, DSH by the Governor, the DSH academy would be received $7.8 million in 2017-18 and $12.4 million unlikely to produce enough graduates to address in 2018-19, as well as three, two-year limited-term the existing officer attrition rate. Accordingly, it is positions. The additional funding allowed the necessary for the academy to continue operating academy to run three sessions annually, with each at some level of expanded capacity—above its session consisting of 50 cadets. Given that not existing baseline capacity—to both reduce the all cadets successfully complete the academy, www.lao.ca.gov 15 analysis full gutter 2019-20 BUDGET Figure 5 Need for DSH Academy Graduates Could Be Met by 2022-23 2019-20 2020-21 2021-22 2022-23 2023-24 Additional officers needed—beginning of year 132.1 79.3 38.5 9.7 -7.1 Number of officers leaving annuallya 85.2 97.2 109.2 121.2 133.2 Reduction in need from new academy graduates -138.0 -138.0 -138.0 -138.0 -138.0 Additional officers needed—end of year 79.3 38.5 9.7 -7.1 -11.9 a Assumes monthly attrition rate of 7.1 in 2019-20, 8.1 in 2020-21, 9.1 in 2021-22, 10.1 in 2022-23, and 11.1 in 2023-24. DSH = Department of State Hospitals. existing vacancy rate and address the projected on an ongoing basis as proposed by the Governor. increase in the attrition rate. This would allow the academy to continue to However, under the Governor’s proposal to produce additional officers to address the projected provide $5.8 million on an ongoing basis, the increase in the attrition rate and lower the vacancy academy could be producing more graduates than rate without resulting in an excess number of necessary beginning in 2022-23, as illustrated in officers in the future. After the three-year period, Figure 5 (see next page). This is because at the the Legislature could reevaluate as part of its end of 2022-23 DSH would have roughly seven deliberations on the 2022-23 budget the number more officers than needed. We note that the of academy graduates needed to meet the security estimates in the figure assume that the attrition needs of the state’s hospitals. rate continues to increase over the next four years. Require Report on Officer Recruitment and To the extent the actual attrition rate is less than Retention. In order to ensure that the Legislature assumed, the academy could be producing excess has sufficient information to provide oversight of graduates at an even earlier date. For example, hospital police officer recruitment and retention if the attrition rate remained at 5.1 officers per and assess future academy graduate needs, we month, the academy could begin producing excess recommend that the Legislature approve trailer graduates in 2020-21. bill language requiring the department to report annually on (1) the officer vacancy rate, (2) the LAO Recommendations officer attrition rate, (3) the number of cadets Approve Funding for Three Years. Given the entering the academy, (4) the number of cadets uncertainty regarding the number of academy who successfully graduate the academy, and graduates that will be needed in the long run to (5) retention rates for successful graduates. This account for officer turnover and vacancies, we information would also allow the Legislature to recommend that the Legislature approve the determine whether adjustments to the level of resources requested to maintain the expanded funding for the DSH Police Academy are needed DSH Police Academy for three years, rather than prior 2022-23. LAO PUBLICATIONS This report was prepared by Drew Soderborg and reviewed by Anthony Simbol. The Legislative Analyst’s Office (LAO) is a nonpartisan office that provides fiscal and policy information and advice to the Legislature. To request publications call (916) 445-4656. This report and others, as well as an e-mail subscription service, are available on the LAO’s website at www.lao.ca.gov. The LAO is located at 925 L Street, Suite 1000, Sacramento, CA 95814. 16 LEGISLATIVE ANALYST’S OFFICE